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Dialadoctor Global
Dialadoctor Global – questionnaire
Your first name
*
Your middle name
Your last name
*
Your sex
*
Male
Female
Prefer not to say
Your date of birth
*
Your e-mail
*
Your phone number
*
Your weight, KG
*
Your height, CM
*
Your address: street, apartment, postal code, city, country
*
Your lifestyle type
*
Active
Moderately active
Passive (sedentary lifestyle)
If other, please specify:
Your blood type
*
I (0)
II (A)
III (B)
IV (AB)
Unknown
Your Rhesus
*
+
-
Unknown
Your national identification number (for FSMP)
*
Do you use any pharmaceutical drugs at present?
*
No
If YES, please write what pharmaceutical drugs you use:
Have you had any surgeries in your lifetime?
*
No
If YES, please write what surgeries did you have:
Additional information (if you want to add anything, please add it here)